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Date Archives: 11-Aug-2017

Question: After consistent review of the new ALS, I just came across something that I am hoping you may clarify for me. In regards to the Medical Cardiac Arrest directive, under the "clinical considerations," it states that under certain circumstances we transport after first rhythm analysis (and lists some examples). In the old ALS, one of these examples was "pediatrics" but now i notice that in the new ALS, also under clinical considerations, it mentions to plan for extrication and transport of pediatric cardiac arrest patients after 3 analyses. So, does this mean we do not transport after first rhythm analysis for pediatrics and must complete the full directive now?

Answer: The majority of peds cardiac arrest cases fall under ‘reversible causes’, so yes, go ahead and transport after one analysis (generally, these will present as Asystole or PEA). However, the directive allows for use of clinical judgment, case by case where you can stay on scene for peds VF/VT.

Very basically, the medical directive allows for transport after the 1st analysis (because most peds arrests are from reversible causes), OR stay on scene for 3 analyses (plus one immediately prior to transport) in cases of shockable rhythms.

Question: My question relates to narcan. Do you feel it is necessary in all cases to check BGL prior to administering narcan? The Medical Directive reads uncorrected hypoglycemia as contraindication but in the presence of no diabetic history and an incident history which is clearly indicating opioid overdose combined with critically low oxygen saturation and no ability to ventilate are we to invariably to take a BGL prior to treating obvious signs and symptoms of opioid overdose or can we use clinical judgement based on findings? It goes without saying that a BGL should eventually be taken on such a patient at some point but my question is with a critical patient, no history or finding consistent with low BGL and multiple indicators for OD are we not safe to presume OD, treat accordingly and follow up with BGL afterwards to rule out hypoglycemia?

Answer: This is a good question to ask. It illustrates the complexity of practice in the real world. The reality of practice is that in emergent situations practitioners do multiple things simultaneously. If there is no urgency to treat the overdose (you are able to ventilate easily etc.) it is reasonable to have your partner obtain the blood glucose while you are assisting ventilations of the patient. If everything points to a narcotic overdose AND there is no indication the patient is a diabetic taking hypoglycemics AND the patient is unstable, it is reasonable to administer Naloxone prior to obtaining a blood glucose determination. As you stated in the question, a blood glucose should be obtained as soon as possible but the priority is to stabilize the patient

Question: In the 2015 ALS Companion Document Version 3.3 pg 13, it states this: "A clinical consideration states "Suspected renal colic patients should routinely be considered for Ketorolac". More correctly, this statement should include NSAIDS like Ibuprofen. Ketorolac is preferred when the patient is unable to tolerate oral medication.

There is some confusion over the interpretation of this. I read this statement as suspected renal colic patients should be routinely screened for an NSAID (not just Ketorolac), and therefore should be given ibuprofen first instead, unless the patient cannot tolerate oral medication. My PPC is saying differently that you should be considering Ketorolac first, since the companion document cannot overrule the ALS Directives. What is the true purpose of this statement then?

Answer: The current analgesia medical directive does generate a lot of confusion. The current directive is the result of compromises made at the time the directive was negotiated. There is an updated comprehensive adult analgesia medical directive currently making its way through the Ministry approval process. The new directive will allow for more liberal use of analgesia. Until it is released, the direction is, assuming no contraindications, to give a patient with suspected renal colic and a history of previous renal colic an NSAID. The directive’s clinical considerations allow for the use of ketorolac as a first line NSAID for this patient population only. Suspected renal colic patients should routinely be considered for ketorolac administration (meaning, first line) because of the anti-inflammatory action and smooth muscle relaxant effects (reduces the glomerular filtration rate which reduces renal pelvic pressure and stimulation of the stretch receptors) as well as its inhibition of prostaglandin production makes them ideal agents to treat renal colic. Ketorolac should not be administered in conjunction with ibuprofen as they are both NSAIDs and concomitant administration of both would increase the adverse effects.

Question: I have a question regarding the administration of narcan. Narcan seems to be given more often now that there is no patch point. The wording of the medical directive hasn't changed though so just to confirm, are we still just to be giving it when we cannot adequately ventilate the patient? Example, if they are GCS of 3 and breathing inadequately but we are getting good compliance on the BVM and the patient’s vitals are otherwise stable, are we ok to not give it? If we do go ahead and give narcan to a patient who is NOT breathing and they start breathing on their own but are still GCS of 3 are we to stop there since we can now manage their airway or do we continue up to our maximum of 3 doses or until they become GCS of 15?

Answer: The treatment for opioid toxicity is adequate ventilation. This can often be obtained with BLS manoeuvers such as utilizing BVM as you describe. Naloxone is used when you are unable to adequately ventilate the patient and they meet the other indications for its use. The endpoint for naloxone use is adequate ventilation NOT an increase in LOC. The area of pre-hospital use of Naloxone (Narcan) is rapidly evolving. The original medical directive was conservative in the indications for Naloxone and how it was used. It reflected safe practice. The administration of small amounts of Naloxone, titrated to allow the patient to breath and emerge slowly, permits paramedic safety and prevents a sudden narcotic withdrawal state in the patient. This remains the goal. Now Naloxone is administered by bystanders and soon by both the Police and Firefighters. The original directive was also developed before more powerful narcotics such as Carfentanyl began arriving on the scene. Overdoses from the more potent narcotics may require larger amounts of Naloxone to reverse the narcotic effect. However, the goal remains the same – to stabilize the patient and allow them to breath on their own without necessarily waking them up to a GCS of 15.

Question: If the Valsalva Maneuver is not a medically controlled act why would a PCP not be able to carry out this procedure for a symptomatic narrow complex, regular rhythm tachycardia that is symptomatic? PCP's are supposed to be able to identify sinus tachycardia, atrial fibrillation or atrial flutter which would be contraindicated and especially if no other immediate care is available. Why such be restricted to only ACP's, again especially if no other immediate care is available?

Answer: Good question. It seems to be a reasonable thing to try for a normotensive patient with symptomatic regular narrow complex tachycardia. It is important to be able to be able to recognize SVT in order to utilize this manoeuver.

Question: Why are all the directives based upon an urban setting assumption given that there are very rural areas in which paramedics work in besides big cities? Further to this, one could suggest that certain advanced skills are more appropriate if not life saving the further from a hospital. Has there ever been any consideration to consider such advanced care skills such as midazolam for seizures, needle thoracostomy, peds IO and even cricothyrotomy to name a few. Why are these not even considered in areas with transport times exceeding well over 1-2hrs. These are skills that overall can make a significant difference in patient outcomes especially when no other care is available. To add, these are not skills that can be deemed to be well learned for even experienced ACP's as actual prevalence even in an urban setting is very low. Thus, the number needed learn position can be put forth ACP's anymore than PCP's but the difference in distance to more advanced care certainly can.

Answer: The answer to your question is complicated. Paramedic scope of practice expanded on the assumption that Emergency Department practices could be moved into the pre-hospital setting for the emergent care of critically ill or injured people. This was based on analogies to the successful reduction of mortality from blood transfusions and forward operating medical capability on the battlefield. It was also clear that survival from conditions such as cardiac arrest from ventricular fibrillation is improved by pre-hospital defibrillation. It made “sense” that early treatment of other conditions would be beneficial. Paramedic scope of practice in Ontario expanded initially in urban areas because it was believed the volume of patients who might potentially benefit from these skills was high and because the response time was relatively low. Initially it was felt that the low volume of cases in rural areas that required specific ALS skills was too small to make the training and maintenance of competence practical. The argument, similar to the one you made in your question, was also made by the provincial MAC’s Rural and Remote Working Group in 2002. The recommendations from that group led to the expansion of PCP skills beyond the 5 original symptom relief drugs and defibrillation capability. Now PCPs start IVs, administer multiple medications, including analgesics in both urban and rural areas. This was all based on the same argument that you made that these paramedic capabilities are even more needed in rural areas.

Unfortunately, the research based evidence for a benefit of any of these added skills is small or non-existent. What evidence we do have, from studies such as OPALS, does not support the “stay and play” approach to trauma. There is evidence that these practices might even be harmful. None of the commonly used medications given in to patients in cardiac arrest have an evidence base for their effectiveness. In rural areas the advanced skills are seldom used. There has been consideration to introduce procedures, such as needle thoracostomy, drugs for seizures, and criothyroidotomy, that you mention. There is evidence that these skills are infrequently used by ACPs, even in urban areas. Despite your claim that these skills “make a significant difference in patient outcomes” there is no evidence other than the occasional anecdotal, case of 1 type evidence, to support that claim. Although we all believe it “should make a difference”, it is difficult to justify the addition of rarely used skills. There is a substantial use of resources to train and maintain the competence to use these skills that might be better used elsewhere. Prehospital research to determine whether many of the ALS procedures are effective or not is extremely difficult and costly to do. The system continues to advance but it will likely advance in small increments for the foreseeable future.

Question: One frustration or perhaps lack of knowing is why the Medical Directives differ so much from province to province even for PCPs. Does "evidence based medicine" stop at provincial borders or is it that interpretation and application of such depends more on who, as well as financial politics and liabilities more than evidence based medicine and timely patient care? I can provide examples but I do not think it is specifically necessary-helpful per say in answering the primary question. Look forward to your response.

Answer: This is a very good question. Evidence Based Medicine does not stop at provincial borders. However, your question assumes that there is one correct, universal, answer to every situation and what is called Evidence Based Medicine is able to provide it. If this was true, then it follows that the directives in different provinces ‘should’ be the same. However, this is not the way it is. Medical Directives are developed through a social process that takes into account many bits of evidence. You mentioned some of the other factors that affect how policy is made, such as finances, past practices, individual beliefs, etc. Each province is different and each time a medical directive is made these factors come into play. Even at a Base Hospital level, there can be multiple interpretations of the same directive. It is frustrating to see different things being done in different places, especially when you disagree with what is being done. There is no simple solution, nor is it likely possible to change the fact that Medical Directives will be different in different places. That is the nature of how policy is made. However, Medical Directives do change, all the time, as new information becomes available.

Question: When the Ministry of Health's DNR forms are filled out, can the section where the patient's name goes have a sticker from the hospital with the patients name/health card #/DOB, etc. instead of having the name printed or does that make the form invalid. The form specifically states the patient’s name should be printed clearly. I wasn't sure if the ID sticker was something we could accept instead or if that section can only be filled out by hand.